Before asking “how”, first ask “why”
TJA is a major surgery with a risk for life-threatening complications. TJA remains a surgery primarily for the elderly population, which is a cohort that commonly presents with comorbidities and a low reserve capacity for managing physiologic stress. Hundreds of thousands of TJA procedures are performed yearly in hospitals worldwide and most centers have effective protocols for postop management and transition to the next level of care.
So why change something that works?
Ambulatory Surgery Centers (ASCs) saves the healthcare system a lot of money. ASCs provide an average of 84% cost reduction in procedures as compared to hospital outpatient departments[1-3]. This is important because cost containment is a major issue for 21st century healthcare, especially for joint arthroplasty, where the yearly numbers are projected to increase consistently over the next decade. Resources are a limited commodity (becoming more limited) and thus its irresponsible to say that cost should not play a role in decisions about care. For example, every patient could stay in the Surgical ICU after a laparoscopic appendectomy because technically its safer (greater nurse to patient ratio, and closer monitoring). But patients are not admitted to the SICU after a lap appy because it is unnecessary care; an excessive expenditure. Maximal medical care is not a patient right, rather, patients have a right to appropriate medical care. So what is the appropriate level of care after a TJA? What function is the hospitalization serving for the patient’s care? The answer is that it depends on the individual patient’s risk profile. Lets look at the steps to determine whether a patient is a good candidate for outpatient joints, and if so, how to streamline the process.
Outpatient surgery is cost effective as long as complications, ER visits and hospital readmissions do not outpace the baseline rate for TJA performed at the hospital. Improper patient selection and/or management of comorbidities, as well as inadequate home setup will make outpatient TJA more costly and more dangerous than hospital-based postoperative care[4]. It is essential to select the right patients, and closely monitor them at home during the early recovery to ensure safety and patient satisfaction.
Appropriate Patient Selection is the Foundation of Outpatient Joints.
Many studies have demonstrated that outpatient TJA is safe in the well-selected patient. [5-10]. Recent national database analysis did not find increased complication rates in outpatient TJA by 30 days [11, 12]. Selection requires a thorough evaluation of current and past medical issues, with particular attention to a history for thromboembolic disease, cardiovascular or cerebrovascular events, and arrhythmias. Such patients are not candidates for the outpatient setting. Patient history and exam must be supplemented by the standard preoperative work-up including: EKG, a complete metabolic panel, complete blood count, and HgbA1C in diabetics.
Making a plan.
Unlike a hospital-based TJA, a lot of the work is front-loaded, utilizing a multi-disciplinary team before the surgery.
Regardless of a patient’s preop fitness, all patients will be functionally limited immediately after the procedure and must arrange for postop care. A patient should select a family member or close friend to stay with them for the first 72 hours after. Ideally this person will attend preoperative evaluations to better understand the circumstances after surgery.
A Joint Arthroplasty Navigator should be part of the process as soon as the patient elects to undergo surgery to manage perioperative expectations, coordinate logistics on the day of surgery, and plan for home care.
A Physical Therapist should meet with the patient pre-op to discuss the therapy protocols and review the living situation and explain post-operative ambulation.
An Anesthesiologist should meet with the patient a week before surgery to confirm the patient was appropriately selected for outpatient TJA and to discuss regional anesthesia options and review pain management protocols.
Perioperative protocols
Anesthesia. Perioperative anesthesia should be based on procedure. THA patients receive lumbar epidural catheters and propofol sedation, while TKA/UKA patients receive regional nerve blocks (ie single dose femoral nerve block, single dose tibial nerve block, and adductor canal catheter) as well as sedation or general anesthesia. Pain catheters are removed by a visiting nurse on postoperative day 2. A knee immobilizer should be worn until removal.
Fluid management. 1-2 L IVF intraoperatively, with 75-100 ml/hr 2-4 hours postoperatively, then discontinue once oral intake begins. Avoid foley catheters. Properly performed spinal or regional block does not impact urinary continence.
Postoperative protocols
Pain control. See multimodal pain protocol.
DVT prophylaxis. Aspirin 325 mg BID (see anticoagulation).
Check up. Daily phone calls from the practice for 7 days to ensure expected recovery. Daily home visits by physical therapy for one week, then 3-4x/week for 4 weeks. Daily home visit by visiting nurse for 7 days. Follow up in office at one week, six weeks and three months.
REFERENCES
1. GAO, MEDICARE: Payment for Ambulatory Surgical Centers Should Be Based on the Hospital Outpatient Payment System, U.S.G.A. Office, Editor. 2006.
2. Bertin, K.C., Minimally invasive outpatient total hip arthroplasty: a financial analysis. Clin Orthop Relat Res, 2005(435): p. 154-63.
3. Aynardi, M., et al., Outpatient surgery as a means of cost reduction in total hip arthroplasty: a case-control study. HSS J, 2014. 10(3): p. 252-5.
4. Hunt, G.R., et al., The consequences of early discharge after hip arthroplasty for patient outcomes and health care costs: comparison of three centres with differing durations of stay. Clin Rehabil, 2009. 23(12): p. 1067-77.
5. Berger, R.A., et al., Rapid rehabilitation and recovery with minimally invasive total hip arthroplasty. Clin Orthop Relat Res, 2004(429): p. 239-47.
6. Berger, R.A., et al., Minimally invasive quadriceps-sparing TKA: results of a comprehensive pathway for outpatient TKA. J Knee Surg, 2006. 19(2): p. 145-8.
7. Berger, R.A., et al., Outpatient total knee arthroplasty with a minimally invasive technique. J Arthroplasty, 2005. 20(7 Suppl 3): p. 33-8.
8. Berger, R.A., et al., Newer anesthesia and rehabilitation protocols enable outpatient hip replacement in selected patients. Clin Orthop Relat Res, 2009. 467(6): p. 1424-30.
9. Pearson, S., I. Moraw, and G.J. Maddern, Clinical pathway management of total knee arthroplasty: a retrospective comparative study. Aust N Z J Surg, 2000. 70(5): p. 351-4.
10. Sanders, S., et al., Perioperative protocols for minimally invasive total knee arthroplasty. J Knee Surg, 2006. 19(2): p. 129-32.
11. Courtney, P.M., A.J. Boniello, and R.A. Berger, Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database. J Arthroplasty, 2017. 32(5): p. 1426-1430.
12. Nelson, S.J., et al., Is Outpatient Total Hip Arthroplasty Safe? J Arthroplasty, 2017. 32(5): p. 1439-1442.